The Teen Epidemic - Consumer Reports (1995)

Excerpted from Consumer Reports electronic services January 1995, reprinted by permission.

Introduction

Over the past three decades, the number of smokers in the U.S. has slowly but steadily declined. But now that progressive trend may come to a halt. The drop in the nation's smoking rate is leveling off, and for a chilling reason: As adult smokers quit, there's a steady supply of teenagers stepping up to replace them.

Every day, 3,000 American teens reach adulthood as confirmed cigarette smokers. That's roughly equal to the number of adults who give up smoking or die from the diseases it causes. Most teens started when they were legally too young to smoke. Kids under 18 smoke an estimated 17 billion of the 500 billion cigarettes sold each year in the U.S. Teens are the primary source of new smokers. After they turn 20, almost no one starts. According to a U.S. government survey, for a group of people in their 30's who'd been daily smokers at some point (or still were), about 46 % began smoking when they were 12 to 15 years old.

"Since the first Surgeon General's report in 1964, the public health movement has been very successful in convincing adults not to start smoking," says John Pierce, an epidemiologist at the University of California, San Diego. "But we've had very little impact on kids."

Today, about one in thee high school seniors say they smoked in the past month, and about one in five smoke daily. That's particularly alarming because, unlike the teens of 30 or 40 years ago, these new smokers know full well how dangerous cigarettes are. They've been hearing for years that tobacco is addictive and deadly.

Anti-tobacco and public-health advocates have tried to adapt their messages to teens, using school programs and aggressive ad campaigns. But they have little to show for their efforts. In California, for instance, a $600-million anti-smoking campaign cut the overall smoking rate by an impressive 30 %. Yet it couldn't make a dent in the teenage smoking rate, even though nearly $150 million of the money went directly into school programs, and much of the general campaign was targeted at adolescents.

The voices of medical reason are up against forces that can overcome teenagers' fear of disease and death -- at least long enough for the teens to become addicted to nicotine. The tobacco industry has waged a relentless campaign to recruit smokers; in spite of being banned from the airwaves, cigarettes are advertised more heavily than any product except cars.

Despite the industry's protests that it has no such intentions, the campaign has clearly snared kids, not only with the infamous Joe Camel, but also with a host of other print advertising, merchandising strategies, and even direct-mail campaigns. Add in the power of peer pressure and the willingness of store owners to sell cigarettes to minors, and it's no wonder that so many teens are hooked.

There is much at stake here. A significant drop in teen-age smoking would cut deep into the tobacco industry's main source of new customers. But from a public-health standpoint, keeping kids away from cigarettes is the single most effective way to fight the nation's leading cause of death.

Reasons Why Teens Smoke

According to University of California epidemiologist John Pierce, many teenagers typically start smoking as an occasional thing. "The overriding thing is the image of being cool," says Pierce. "They all think they're not going to get addicted, that they can stop, but they can't."

Of course, teens grow up in a culture that's long been permeated with attractive images of smokers and cigarettes. Hollywood does its share, but it's the cigarette makers who have so wallpapered our world that their ads and logos are inescapable. The images they emphasize resonate perfectly with the psychological and social needs of adolescents.

The Need for Social Acceptance

Cigarette ads play to the craving for popularity: Newport ads invariably feature confident-looking young couples having fun together, often with an erotic sub text. Camel ads call Joe a "smooth character." With his saxophone, his panache, his Ray-Bans and his trendy wardrobe, Joe looks "smooth." (At a high school Consumer Reports visited, one boy who apparently had absorbed the ads' message volunteered that Camels were popular among kids because "they're the strongest and smoothest.")

Asserting Personal Independence

One of the main developmental tasks of adolescence is to assert independence from one's parents by constructing one's own identity. Marlboro has successfully exploited that need for years with its cowboy. A Virginia Slims campaign last spring said the cigarette was "as free-spirited as you."

The theme of weight control plays into many teenage girls' preoccupation with thin figures. Mistys are "slim and sassy," and a Virginia Slims ad says, "If I ran the world, calories wouldn't count." The models in the ads are extremely thin, wearing fashionable clothes. Even the cigarettes themselves are extra-slender.

The Message Behind the "Garbage

Advertisements are just a small part of the tobacco industry's campaign. Cigarette makers spend nearly half their marketing money on so-called "value added" promotions like coupons and premiums. Some you can pick up right at the store with your cigarettes. With two packs you get a flashlight or can holder. With four packs you get a baseball cap, and with five you get a T-shirt.

Cigarette makers also rely heavily on catalog promotions. Customers amass bar-codes or certificates ("Camel Cash" is the best-known example) to trade for merchandise. Marlboro has sent vans around to convenience-store parking lots so customers can redeem their "Marlboro miles" on the spot. Many products in the catalogs would appeal to adolescents. A Virginia Slims "V-wear" catalog last year featured temporary tattoos. A "Camel Cash" catalog included a suede baseball jacket, a beach towel and a charm bracelet.

Though the catalog order forms require customers to state that they're over 21, these products do find their way into the hands of minors. John Slade, a physician at the University of Medicine and Dentistry of New Jersey who studies tobacco marketing, conducted a nationwide phone survey of children 12 to 17. He found that 11 % owned at least one promotional item.

Mail-order promotions have enabled tobacco companies to build enormous direct-mail lists of smokers. Slade's poll found that 7.6 % of teenagers had received cigarette companies' mail addressed directly to them. Extrapolating to the entire U.S. population this age, Slade estimates that there are 1.6 million teenagers' names on the companies' mailing lists.

Who's the target?

Cigarette marketers have a dilemma. Their industry code says they must aim their sales pitch at adults. But market research shows that nearly all smokers start smoking, and become loyal to a specific brand, before adulthood.

The companies insist their marketing efforts don't intentionally target teenagers. The $5 billion they spend every year on advertising and promotion, they say, is intended to promote their brands among adults who already smoke.

There's abundant evidence that, whether or not the companies plan it, children of all ages are paying close attention to their messages. Nothing captures this issue as well as R.J. Reynolds's Joe Camel. In 1991, University of Georgia researcher Paul Fischer found that 30 % of three-year-olds, and 91 % of six-year-olds, could match the Joe Camel character with the cigarette it was promoting. At the same time, Joseph DiFranza, a physician at the University of Massachusetts who researches tobacco promotion, found that nearly 98 % of high-school students recognized the character, versus 72 % of adults.

R.J. Reynolds denied targeting children and hired Richard Mizersky, a University of Florida marketing researcher, to repeat the Fischer study. Like Fischer, Mizersky found high recognition rates. But he also asked the children whether they liked cigarettes, and found that "there's clearly no link between recognition and liking." While 41 % of three-year-olds said they liked cigarettes, less than 4 % of the six-year-olds said so. Other researchers point out that the response to a straightforward question like Mizersky's may not predict behavior. Even if children tell a researcher they don't like cigarettes, they're likely to change their minds many times before adolescence.

Ad Dollars and Teen Smokers

Cigarette makers say their ads are aimed at adults, not kids. But the more money spent on print and outdoor advertising for a particular brand, the more popular it is among underage smokers. Adult smoking preferences don't follow spending quite as closely.

Here is a summary of the major brand advertising costs, in millions, their share of the 12 - 18 year market, and their share of the overall U. S. market share.

Persuaded To Buy?

If you ask teenagers, they'll insist that they could never, ever be influenced by an ad. But tobacco-marketing researcher John Slade says this attitude is to be expected. "Advertising at its best leaves impressions and influences people without their noticing it," Dr. Slade says. "It doesn't surprise me that's what people say. But look at what they do."

In fact, there's abundant evidence that cigarette advertising effectively reaches kids before they're even out of middle school, shaping their perceptions and behavior. Several studies have found that adolescents consistently overestimate the number of people who smoke (thinking that smoking is more socially acceptable than it is). Youngsters exposed to the most advertising most greatly overestimate the number of smokers. When kids begin to experiment with smoking, they do so with the most heavily advertised brands.

That certainly appears to have been the case with Camels. In 1986, the brand's market share among 17-to-24-year-olds was less than 3 %. In 1988, Joe Camel was introduced. By 1989, the market share among underage smokers was 8 %. By 1993, the share among underage smokers had risen to 13 %.

John Pierce, of the University of California, has used decades' worth of federal health-interview data to reconstruct the change in cigarette brand shares over time, and found they consistently correlate with ad campaigns. For example, the percentage of teenage girls who started smoking regularly rose sharply in the late 1960's with the introduction of Virginia Slims, the first cigarette brand designed and marketed specifically for women. During the same period, the rate for boys didn't change.

Peer Influence and Easy Access

One theory that seeks to explain tobacco use is put forth by epidemiologist John Pierce, of the University of California. What's happening, Pierce thinks, is that "advertising makes people susceptible" to experimenting with smoking. "But once they're susceptible, advertising doesn't make them want to experiment. Exposure to peers does."

Based on polling of California schoolchildren, Pierce and his colleagues have developed a "smoking-susceptibility" scale that captures this process. The first rung on Pierce's smoking-susceptibility scale is awareness of ads, which is all but universal. The next steps include believing the ads promote smoking's benefits, having a favorite ad, having a favorite brand, and either owning a cigarette promotional item or being willing to wear one. Kids who score highest on the scale are four times as likely as the lowest-scoring kids to say they might try a cigarette if one of their best friends offered it.

Many studies have established that having a circle of smoking friends powerfully predisposes children to experiment with smoking. Based on interviews with some 5,000 Californians aged 12 to 17, Pierce found that teenagers who had best friends of both sexes who smoked were 13 times as likely to have smoked within the past month as youngsters without smoking friends.

Fortunately, four out of five people make it through high school without becoming daily smokers. Those who do start smoking, research has shown, tend to share certain risk factors: low socioeconomic status, poor school achievement, excessive rebelliousness and risk-taking, low self-esteem, dropping out of school, and not planning on college.

In a cultural shift that has caught public-health authorities by surprise, the smoking rate among black teens, which once matched that of white teens, has dropped steadily since 1976. The percentage of black high-school seniors who smoke daily is now just 4 %, compared with 23 % among whites. Health researchers are furiously seeking an explanation. "We want to bottle it, so we can sustain it for black teens and pass it along to white teens," says Michael Eriksen, director of the U.S. Centers for Disease Control and Prevention's Office on Smoking and Health.

Easy to Buy

Teens primed by ads and surrounded by friends who smoke just need a ready source of cigarettes to allow them to progress to outright addiction. No problem.

Although every state outlaws the sale of tobacco products to anyone under 18, study after study has documented that those laws go almost completely unenforced. Some stores are careful not to sell to underage teens, but not enough. The youngest smokers often say they buy their cigarettes from vending machines.

Under public pressure, cigarette makers and the Tobacco Institute have attempted to address the problem in several ways. For example, they give tobacco retailers stickers to post by the cash register reminding teenagers that they can't legally buy cigarettes. But the stickers don't appear to make clerks less willing to sell to teens.

Dr. Joseph DiFranza, a University of Massachusetts researcher, took five underage teenagers to 156 central Massachusetts stores. They were able to buy cigarettes at 137 stores, including six of the seven displaying the sticker.

Snuff: Another Marketing "Triumph"

Most kids have tried smoking tobacco. But few of them sucked on it, until after the "smokeless tobacco" industry launched an aggressive, 20-year campaign to attract new customers. According to a report the U.S. Surgeon General issued last year, the promotional effort succeeded in greatly increasing the product's use among the young.

In 1970, federal surveys found that 3.4 % of men over 65 habitually "dipped" snuff, compared with fewer than 1 % of men aged 18 to 24. Then ads and promotions from U.S. Tobacco (which dominates the market) started associating snuff with rodeos, rock stars and monster trucks.

Like cigarette makers, snuff makers zealously deny marketing their products to the underage users. But some ads appeared to "target male adolescents," the Surgeon General said, "by providing explicit instructions for use (sometimes delivered by well-known professional athletes) and by suggesting that the product could be used without adult detection."

By 1991, use of snuff had risen more than 10 times among young men (to 7.5 %) while actually declining by about one-third among male senior citizens. It's illegal to sell snuff to anyone under 18. But among teenaged boys, its use is now nearly as common as that of cigarettes.

The way snuff is packaged and formulated helps new users to gradually take up the habit and advance to products with stronger tastes and higher nicotine absorption, the Surgeon General said. And addiction is common. The nicotine readily enters the bloodstream through the mouth's mucous membranes, and users who try to quit suffer withdrawal symptoms just as severe as a smoker's.

Bathing your mouth daily in an alkaline tobacco solution has health consequences far more immediate than those from smoking cigarettes. The most serious is oral cancer. Studies have found precancerous patches of tissue in the mouths of about half of current teenage users. With continued tobacco use, about 1 in 20 such lesions will become cancerous within five years.

Smokeless tobacco is also terrible for the gums, which become inflamed and recede. About one-third of teenage users develop that condition. For these reasons, in 1986 the Surgeon General's report concluded that there was "no safe use" of smokeless tobacco.

What Should be Done

According to the latest data, half of all lifelong smokers will die prematurely, an average of eight years early. For that reason alone, halting the teenage smoking epidemic must be a public-health priority. But how?

Last year, an expert panel of the National Academy of Sciences addressed the question and recommended three major strategies: Banning nearly all cigarette advertising and promotion, raising cigarette taxes to make smoking less affordable, and enforcing the laws against selling to teens.

Advertising

Ideally, Consumer Reports would like to see Congress ban all cigarette advertising and all promotional uses of cigarette logos. Many tobacco-control activists have sought to ban cigarette advertising for years, and it often gains majority support in public-opinion polls. A challenge on the First Amendment grounds would be likely, but many legal scholars believe the Supreme Court would uphold the restriction.

The tobacco industry argues that teen smoking rates haven't changed much in countries that have enacted such bans. But the most comprehensive review done on the subject, by New Zealand health officials in 1989, found that teenage smoking rates declined faster in countries with stricter ad bans.

Advertising bans would be more effective, too, if marketers didn't find so many ways to evade them. Canada banned ads, but left one loophole: Companies could still sponsor cultural and sporting events. The companies do, and make sure that every poster, advertisement, billboard or program contains a large image of the brand's logo and name.

Given the present political realities in Washington, a national ban on cigarette advertising is unlikely. But states and communities can and should take their own steps to reduce teenage smoking, through both law enforcement and taxation.

Restricting Sales

Another way to halt the teenage smoking epidemic is to restrict sales. In 1992, Congress enacted the Synar Amendment, which requires states to put teeth into their laws against selling cigarettes to minors, or lose much-needed federal money for drug and alcohol treatment. The Synar Amendment has gone unenforced for nearly three years, awaiting clearance of the regulations by the Office of Management and Budget. In the meantime, any real progress on enforcing sales laws has occurred at the local level.

In communities where police rigorously enforce the law, sales and teen smoking drop. In Solano County, California, intensive enforcement of sales laws reduced the percentage of stores selling to minors from 72 % to 21 %.

One problem is the extra work this can impose on police. To get around that, some communities have licensed tobacco retailers in the same way liquor stores are licensed. The licensing fees pay for enforcement. License laws provide a strong incentive for retailers to card young-looking customers. If they're not careful, they could lose their license and thus lose the lucrative adult trade, as well.

In the year and a half after Woodridge, Illinois, began licensing cigarette retailers, surveys found the proportion of seventh- and eighth-graders who reported experimenting with cigarettes fell from 46 % to 23 %, and the proportion of daily smokers fell from 16 % to 5 %. Over that same period, compliance checks found that the proportion of stores willing to sell to minors fell from 70 % to 3 %.

But restricting store sales will be nearly meaningless if teens are still able to buy cigarettes from vending machines. The machines should be banned, as they already are in some communities.

Boosting Cigarette Taxes

In 1982, Canada boosted cigarette taxes to among the highest in the world. Teenage smokers turned out to be unwilling or unable to pay $4 or more for a pack of cigarettes: The youth smoking rate dropped from 40 % in 1981 to just 16 % in 1991.

Unfortunately, Canada also learned that when you lower the price, teen smoking goes up. Under political pressure from the tobacco industry, Canadian lawmakers rolled back the tax in February 1994 and prices dropped again. By the end of 1994, teenage smoking rates had already climbed back up to 19 %.

How to Help a Teen

Adolescents start smoking for many intermingled reasons. Some factors that seem to fortify children against tobacco experimentation are built up slowly from toddlerhood on and can't be provided overnight when a child reaches the high-risk age of 12 or 13: self-esteem, academic achievement, skills for dealing with peer influence and a close parent-child relationship. Still, if you're looking for ideas, there are several steps you can try to help your children shun cigarettes.

Talk. Children whose parents don't talk to them regularly are at greater risk for experimenting with cigarettes. Make a point of discussing your children's lives and feelings. Make sure you know their friends (and the friends' parents). That will help you find out whether any of the friends is trying out smoking, so you can talk about it with your own child.

Make your feelings clear. Children who understand the depth of their parents' opposition to it are less likely to smoke.

Help children decode ads. Ideally, you should begin as early as the fourth or fifth grade, when children may first become susceptible to the images in cigarette ads. Urge them to identify seductive images.

Give them a reality check. Point out (perhaps while walking past office workers smoking in doors and alleys) that, despite the ads, the vast majority of adults do not smoke and no longer even tolerate the practice in public.

Emphasize health. Kids are notoriously unconcerned about getting sick. Tell them anyway: Teenage smokers have weaker lungs, cough more and suffer worse upper-respiratory infections. Young athletes don't perform as well if they smoke. The more years a person smokes, the greater the risk of lung cancer in middle age.

Emphasize addiction. Nicotine is so addictive that some experts compare it to heroin. And, once hooked, kids find it just as hard to kick the habit as adults do. Trouble is, there's no way to predict which kids will become addicted. So it's best not even to experiment.

Help them say no. This technique is used in many formal substance-abuse prevention courses in school but can easily be adapted at home. As best as you can, play the part of an admired friend or acquaintance trying to get your teenager to try a cigarette. Help your child work out ways to turn down the offer.

Don't smoke. If you're a smoker and are unable or unwilling to quit, at least explain to your children that you are in the grip of a fearsome addiction, and hide your cigarettes. Smoke less in front of your children and make their rooms smoke-free zones.

Impose consequences. If, in spite of your efforts, you find your child experimenting with cigarettes, do not treat it as a minor "kids-will-be-kids" infraction. Treat it as what it is: an act that puts your child at very high risk of developing a life-threatening addiction. Impose whatever sanctions your family uses for a major misdeed. And don't back down.

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© 1995 by Consumers Union of U.S., Inc., Yonkers, NY 10703. Excerpted by permission for educational purposes from the January 1995 issue of Consumer Reports. No downloading, photocopying or re-transmitting permitted. To subscribe or to order a copy of the complete article for $3.00 each from the following address or call 1-800-234-1645. You can visit Consumers Union at http://www.ConsumerReports.org/.

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